'High Value' Care Goal of New ACP Partnership

NEW ORLEANS -- The American College of Physicians (ACP) and Consumer Reports are teaming up to help patients get the biggest bang for their healthcare bucks, starting with management of low back pain and diabetes, officials of both groups said here.

In a joint program called High Value Care, the two organizations are developing brief, to-the-point brochures that advise on expensive tests and treatments to avoid because they lack evidence that their benefits outweigh the costs and risks.

The brochures would be made available primarily via the Internet but would also be used in some form in the Consumer Reports print magazine and other products.

The first two brochures in the program were unveiled at the ACP's annual meeting. One tells patients with low back pain why they "probably don't need" x-ray, CT, or MRI scans; the other says that metformin is the best first-line drug for type 2 diabetes in most patients.

Other topics to be covered in future brochures have not been determined, but some of the most likely would be cancer screenings and imaging for headache and syncope, officials said at a press briefing.

The program seeks to bring clinical practice recommendations developed by the ACP and published in its flagship journal, Annals of Internal Medicine, to patients in language they can more easily understand.

The brochures will be posted in Spanish and English on the ACP, Annals, and Consumer Reports websites. Videos and versions for low-literacy patients are in the works as well, said John Santa, MD, MPH, director of Consumer Reports' Health Ratings Center.

"We are jointly committed to putting the brakes on overtesting and overtreatment, and we agree that consumers will benefit when either patients or doctors initiate conversations about these delicate issues," said Santa.

The low back pain brochure tells patients that most people "feel better in about a month -- whether they get an imaging test or not."

It also cites studies finding that patients who receive imaging scans are more likely to have surgery and incur markedly higher expenses without any improvement in recovery time, as well as exposing patients to increased cancer risks from the radiation.

But the brochure does note that imaging tests can be appropriate in some cases and lists some of them, as well as a series of "red flags" such as fever or incontinence.

The diabetes brochure promotes metformin as more effective, far less costly, and generally safer than newer medications including thiazolidinediones, incretin-type peptide drugs, and insulin secretagogues.

As in the low back pain piece, however, the brochure indicates that other agents have a legitimate role in diabetes management. Metformin is contraindicated in patients with heart failure and moderate to severe kidney disease, it says.

"In addition, lifestyle changes combined with metformin don't always lower blood sugar levels enough," the brochure says. "In those cases, it is often necessary to add a second drug."

Each brochure also includes a sidebar titled "Consumer Reports Advice." In the diabetes piece, it recommends diet-and-exercise lifestyle changes as well as seeking care from more than just a primary care physician, based on the magazine's subscriber surveys.

"Certified diabetes educators, endocrinologists, and registered dietitians were among the providers that our survey respondents said most considered their specific needs," according to the sidebar.

ACP CEO and executive vice president, Steven Weinberger, MD, noted that the ACP has been promoting the concept of high value care since 2007, when it published the first in what has become a series of recommendations on avoiding unnecessary tests and treatments.

"As we looked at this, it became clear that what we educate physicians about also needs to have a component related to education of patients," he said. "It is because of this that the partnership with Consumer Reports is so exciting in our minds."

He also noted that, although Annals publishes evidence-based recommendations from the U.S. Preventive Services Task Force that may cover the same ground, it would remain independent of the Choose Wisely and High Value Care programs.

Weinberger and Santa both said they had taken great care to eliminate industry influence on the clinical practice recommendations and their translations for consumers.

ACP guideline committees are largely composed of specialists in evidence review and synthesis, rather than subject matter experts, Weinberger said, and hence are nearly always free of financial conflicts of interest.

Santa said that Consumer Reports subjected the ACP guidelines to its own rigorous review, pursuant to its longstanding policy against commercial influence of any kind.

Many physicians say fear of malpractice suits drives much of what is deemed to be overuse of tests and treatments. The ACP's president, Virginia Hood, MBBS, told reporters at the press briefing that patient education efforts could help eliminate the need for defensive medicine.

"We have to work with our patients and educate them about what works and what doesn't work, and then they can be our best allies," said Hood.

"By coming out with guidelines, by coming out with evidence-based information, that will relieve physicians of being put in a position that ... they should do something that actually isn't necessary just to save themselves from a lawsuit," she added.

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